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The Ethics of Erasing a Bad Memory

“She was worried about the lump and worried about the children who were worrying about her. She was, however, most worried about the anesthesia. "What if I don't wake up?" just wasn't a question I could answer sufficiently for her…. So I warned her that there might be a little pain and agreed to do her biopsy under a local anesthetic — but only if she would allow an anesthesiologist in the room, just in case.

The lump was growing near — maybe on — the inner end of Ellen's collarbone, meaning that during the biopsy I might have to use a tool that goes, "crunch." It's pretty hard to numb-up bone with a local anesthetic so I was glad to have Frank, the anesthesiologist, there at the head of the table with some IV sedatives, in case Ellen got panicky or was in too much pain. She was adamant about not going under, but agreed to "some sedation" if we thought it was necessary. […]

Ellen's procedure got off to a fine start. She was O.K. with the needle-sticks for the lidocaine and she stayed calm and collected under the layers of paper and plastic that we used to drape-off the surgical site. [...]

I ordered up a touch prep — a quick microscopic look at the cells of the specimen. We would know in 15 minutes if there were cancer in the lump. While the specimen was in the pathology lab [...] I made small talk with Ellen and the nurses. Ellen was O.K. but nervous. She talked about her kids, about how much driving she did everyday shuttling them around. The topic of the tumor, and what it had looked like, was given wide berth by all of us. I finished stitching, but I had to stay scrubbed — we couldn't take off the drapes until pathology told us they had a sufficient specimen. There wasn't much else to discuss; it was real quiet and, rare for the OR, a little bit awkward.

"Dr. Haig?" A voice over the intercom, harsh and loud.

"Yes," I said. "Is this path lab?"

"Yes, can I put on Dr. Morales?" the voice replied, referring to the pathologist looking at the microscope slides of Ellen's specimen.

"Have him call in on the phone," I said. The drill, which everyone knew, was that the circulating nurse would hold the phone to my ear while the pathologist told me what he saw.

But instead of an "O.K." there was silence, and then, "Scott, this is Jorge, can you hear me?"

"Yes, but hold on, we're under local in here," I said. "You'd better call the desk and have them put you through to the phone in the room."

"Scott, I can barely hear you but, listen, this is a wildly pleomorphic tumor, very anaplastic. I can't tell..."

The burning pain in Ellen's arm was due to the rapid application of propofol, a paper-white liquid medication, which the perceptive Dr. Frank had plugged into Ellen's IV the second he heard the c-word. When he saw her reaction, he pushed. The drug, sometimes called "milk of amnesia," stings some patients sharply in the veins, but what it also does is erase your last few minutes. (Think of the "neuralyzer" from the Men in Black movies.) Oh, and it puts you to sleep. An amazing molecule, a great anesthesiologist and a great save.

Not everyone agreed. I looked up at three sets of eyes, the nurses' eyes, that bored into Frank and me accusingly. How can you do that? They demanded to know. Don't you need consent or at least fill out some kind of form before you steal a patient's last 10 minutes? But all I could say was, "Awesome job, Frank." Somehow with that, and with the calm sleep on their patient's face, we were given not forgiveness, but a reprieve.

Ten minutes later Ellen woke up, happy and even-keeled, not even knowing she'd been asleep. From the recovery room she was home in time for dinner. "The procedure went smoothly, but we'll have to wait for the final pathology reports," I said, which was not exactly the whole truth, but it let me get the oncology people cued up, a proper diagnosis, and Ellen herself emotionally prepared. I would give her the bad news at a more appropriate time.

The ending was not quite happy; it was a recurrence of the cancer she'd had years before — fairly rare for that type of tumor. Ellen died of it about six years later. I confess I never told her about the incident with the intercom.

Over a decade later, I'm still not sure that was right.

Questions of withholding bad news, wiping out bad memories — plastering-over wayward cracks in our minds with chemicals — are answered thousands of times everyday, without ever being asked. Ethics committees and experts exist in our hospitals, but what they have to say counts precious little down in the trenches, where intercoms fail and human minds treat human minds, in real time. You would think, by now, that the distinction between treatments using words (or ideas) and chemicals (or electric currents) is starting to blur. (If an hour of psychotherapy accomplishes the same thing as 20 mg of Prozac — that is, a boost in mood and serotonin levels — is there a difference?) But it is not. Everyone I know who deals with medicines that affect minds seems to operate with a very clear functional distinction between personhood — the realm of virtue, vice, responsibility and creativity — and brain chemistry. That distinction was clear in the eyes of my nurses that day. Something more important than a chemical balance in Ellen's brain had been violated — only a little and, obviously, with benevolent intent. But it hadn't been as simple as pushing a rewind button. Something there had borne the unmistakable quality of wrong. [...]"

The doctors were clearly acting with compassion and with their patient’s best interests in mind. Wouldn’t it be better for Ellen if she only learned of her cancer after being mentally prepared, and only after a final, complete pathology report? On the other hand, looking at the bare facts, I can’t get over the lack of informed consent. Ellen had clearly expressed her wishes against the use of general anesthesia, and I can only guess how she would have felt about unknowingly losing 10 minutes of her memory.

The rational part of me thinks the doctors should have let Ellen deal with the consequences of her choice, for better or for worse.

Why is everyone who drives slower than me an idiot, and everyone who drives faster a maniac?

Ahhhggggg... Ethics... It makes my head hurt. (I suppose, in a way, that is a good thing. It means I still have a conscience.)

On one hand, she had specifically stated she did not want to be put under, and the doctor's actions violated that. And then he did not tell her about it, which means what she thinks happens in that biopsy is a lie.

On the other, if the woman had suffered a ballistic panic attack in the OR, she could have badly hurt herself against the machines and operating equipment. (I don't know about the proximity of sharp, pointy things during a biopsy, so I don't know it that would be an issue. Jeriddian?), as well as caused herself severe emotional trauma. The doctors and nurses could have been injured trying to restrain her; adrenaline and fear can do some crazy things. So on that footing, the doctor was right to conk her out until she was ready to accept it, as was stated in the article.

...And on the third had that just sprouted out of my sternum, I suggest that they should have gotten their intercom fixed beforehand. :P

---

On a side note, the topic and its title are reminding me strongly of "Eternal Sunshine of the Spotless Mind."

Carpe Navi: Because you never know when you'll get to go boating at government expense again.

On a side note, the topic and its title are reminding me strongly of "Eternal Sunshine of the Spotless Mind."

That title sounds familiar. What was the movie about?

"ESotSM" is about a romantic pair who decide to get their memories of each other erased after the relationship goes sour. With their minds wiped of each other, they inadvertantly fall in love again; the relationship goes sour, and they decide to get their memories of each other erased...

From the "ESotSM" entry on Wikipedia:

"Targeted memory erasure"
Targeted memory erasure is a fictional non-surgical procedure. Its purpose is the focused erasure of memories, particularly unwanted and painful memories, and it is a mild form of brain damage comparable to a "night of heavy drinking". The procedure is performed exclusively by Lacuna Incorporated.

Carpe Navi: Because you never know when you'll get to go boating at government expense again.

The doctors were clearly acting with compassion and with their patient’s best interests in mind. Wouldn’t it be better for Ellen if she only learned of her cancer after being mentally prepared, and only after a final, complete pathology report? On the other hand, looking at the bare facts, I can’t get over the lack of informed consent. Ellen had clearly expressed her wishes against the use of general anesthesia, and I can only guess how she would have felt about unknowingly losing 10 minutes of her memory.

The rational part of me thinks the doctors should have let Ellen deal with the consequences of her choice, for better or for worse.

The problem with this scenario is that there seems to be some inaccuracy. It doesn't make sense. There was no reason for the orthopedic surgeon to send off a prep. These prep's are frozen samples for immediate diagnosis so that a decision about what to do during a surgery can be made. But there was no surgery going on at the time. The procedure described is a simple excision of a subdermal mass, not major surgery. Considering that the patient had a history of cancer before, it is a no brainer that this is most likely a recurrence. As a result, there is no reason whatsoever to have an anaesthesiologist in the room ready to go at a moment's notice because this is a metastasis, and if you have metastasis, there is no reason whatsoever for any kind of emergency surgery for the cancer in and of itself. Metastasis of cancer almost always precludes any kind of surgery anyway, except for debulking procedures. Therefore, there is no need for anaesthesia to be there, not to mention the fact that orthopedic surgeons don't do cancer surgeries (unless he was doing his residency at the time, maybe, but I don't think that's the case here.).

The only way I can see this working is if the orthopedic surgeon actually did have her in the OR to do some orthopedic procedure, but then incidently discovered this lump on her collarbone and knew of her history of cancer. It was proper to consider then that if she had a recurrence of cancer, the orthopedic procedure he was doing needed to be cancelled until the cancer recurrence was worked up. But if this was the case, the surgeon did a very poor job at the initial history and physical. The physical exam should have revealed such an easily discoverable tumor, and they should never have gone so far as to get to the OR for an orthopedic procedure at all before the tumor was discovered and the workup on that tumor was done.

For some reason, the orthopedic surgeon sent off the mass for immediate diagnosis. I can't see where this was necessary. It would have made no difference to wait one or two days to get the diagnosis of anaplastic cancer. Unfortunately, because he did it this way, the pathology laboratory knew it was a frozen prep from the OR and therefore it had to processed and reported immediately, which was what the pathologist did. He assumed he was free to speak because he would assume that the patient was asleep under anaesthesia during surgery. Unfortunately, the patient was awake, and did hear the diagnosis. Then orthopedic surgeon acted by giving her propofol in order to prevent her from being hysterical. It was the safe call, and did take out ten minutes of memory. Technically, it did not actually violate her wishes to not be under anaesthesia, since propofol is actually considered sedation. Nothing can be done about the loss of memory, though.

But I think the orthopedic surgeon made two initial errors here. First, by having a this patient in an OR with an obvious tumor that had not been worked up (if my scenario about her needing an orthopedic surgery is correct. Otherwise there simply was no reason for the orthopedic surgeon to have her there). Two, by sending off a frozen prep when it was not necessary in the first place, thus initiating the unfortunate turn of events. Granted, I don't have all the facts, but it was not handled well at all IMO.

Technically, it did not actually violate her wishes to not be under anaesthesia, since propofol is actually considered sedation.

Hmm, that's interesting. I guess I'm not very clear on the distinction in this case. I thought general anesthesia made a patient unconscious/asleep, and propofol did/does the same thing. What am I missing? Is it a difference in the mode of action of the drugs as opposed to their effect that distinguishes the two?

"ESotSM" is about a romantic pair who decide to get their memories of each other erased after the relationship goes sour. With their minds wiped of each other, they inadvertantly fall in love again; the relationship goes sour, and they decide to get their memories of each other erased...

Sounds like the nightmare version of Groundhog Day. :P

Why is everyone who drives slower than me an idiot, and everyone who drives faster a maniac?

"ESotSM" is about a romantic pair who decide to get their memories of each other erased after the relationship goes sour. With their minds wiped of each other, they inadvertantly fall in love again; the relationship goes sour, and they decide to get their memories of each other erased...

Technically, it did not actually violate her wishes to not be under anaesthesia, since propofol is actually considered sedation.

Hmm, that's interesting. I guess I'm not very clear on the distinction in this case. I thought general anesthesia made a patient unconscious/asleep, and propofol did/does the same thing. What am I missing? Is it a difference in the mode of action of the drugs as opposed to their effect that distinguishes the two?

Sedation does not cause unconsciousness, just enough drowsiness that the patient usually does go to sleep on his own, and so technically Propofol doesn't do that, but it does cause memory loss. People on Propofol usually go on to sleep, but it is not the forced sleep of anaesthesia. That's the distinction. I've had people on Propofol who remained conscious, but they never remember what happened while they were on it.